Medical Black Humor, that is Neither Funny nor Appropriate.

19092011

Last week, I happened to see this Facebook post of the The Medical Registrar where she offends a GP, Anne Marie Cunningham*, who wrote a critical post about black medical humor at her blog “Wishful Thinking in Medical Education”. I couldn’t resist placing a likewise “funny” comment in this hostile environment where everyone seemed to agree (till then) and try to beat each other in levels of wittiness (“most naive child like GP ever” – “literally the most boring blog I have ever read”, “someone hasn’t met many midwives in that ivory tower there.”, ~ insulting for a trout etc.):

“Makes no comment, other than anyone who uses terms like “humourless old trout” for a GP who raises a relevant point at her blog is an arrogant jerk and an unempathetic bastard, until proven otherwise… No, seriously, from a patient’s viewpoint terms like “labia ward” are indeed derogatory and should be avoided on open social media platforms.”

I was angered, because it is so easy to attack someone personally instead of discussing the issues raised.

Perhaps you first want to read the post of Anne Marie yourself (and please pay attention to the comments too).

Anne Marie mainly discusses her feelings after she came across a discussion between several male doctors on Twitter using slang like ‘labia ward’ and ‘birthing sheds’ for birth wards, “cabbage patch” to refer to the intensive care and madwives for midwives (midwitches is another one). She discussed it with the doctors in question, but only one of them admitted he had perhaps misjudged sending the tweet. After consulting other professionals privately, she writes a post on her blog without revealing the identity of the doctors involved. She also puts it in a wider context by referring to the medical literature on professionalism and black humour quoting Berk (and others):

“Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Those individuals who are the most vulnerable and powerless in the clinical environment – students, patients and patients’ families – have become the targets of the abuse. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion.”

The doctors involved do not make any effort to explain what motivated them. But two female anesthetic registrars frankly comment to the post of Anne Marie (one of them having created the term “labia ward”, thereby disproving that this term is misogynic per se). Both explain that using such slang terms isn’t about insulting anyone and that they are still professionals caring for patients:

It is about coping, and still caring, without either going insane or crying at work (try to avoid that – wait until I’m at home). Because we can’t fall apart. We have to be able to come out of resus, where we’ve just been unable to save a baby from cotdeath, and cope with being shouted and sworn at be someone cross at being kept waiting to be seen about a cut finger. To our patients we must be cool, calm professionals. But to our friends, and colleagues, we will joke about things that others would recoil from in horror. Because it beats rocking backwards and forwards in the country.

[Just a detail, but “Labia ward” is a simple play on words to portray that not all women in the “Labor Ward” are involved in labor. However, this too is misnomer. Labia have little to do with severe pre-eclampsia, intra-uterine death or a late termination of pregnancy]

To a certain extent medical slang is understandable, but it should stay behind the doors of the ward or at least not be said in a context that could offend colleagues and patients or their carers. And that is the entire issue. The discussion here was on Twitter, which is an open platform. Tweets are not private and can be read by other doctors, midwives, the NHS and patients. Or as e-Patient Dave expresses so eloquently:

I say, one is responsible for one’s public statements. Cussing to one’s buddies on a tram is not the same as cussing in a corner booth at the pub. If you want to use venting vocabulary in a circle, use email with CC’s, or a Google+ Circle.One may claim – ONCE – ignorance, as in, “Oh, others could see that??” It must, I say, then be accompanied by an earnest “Oh crap!!” Beyond that, it’s as rude as cussing in a streetcorner crowd.

Furthermore, it seemed the tweet served no other goal as to be satirical, sardonic, sarcastic and subversive (words in the bio of the anesthetist concerned). And sarcasm isn’t limited to this one or two tweets. Just the other day he was insulting to a medical student saying among other things:“I haven’t got anything against you. I don’t even know you. I can’t decide whether it’s paranoia, or narcissism, you have”.

We are not talking about restriction of “free speech” here. Doctors just have to think twice before they say something, anything on Twitter and Facebook, especially when they are presenting themselves as MD. Not only because it can be offensive to colleagues and patients, but also because they have a role model function for younger doctors and medical students.

Isolated tweets of one or two doctors using slang is not the biggest problem, in my opinion. What I found far more worrying, was the arrogant and insulting comment at Facebook and the massive support it got from other doctors and medical students. Apparently there are many “I-like-to-exhibit-my-dark-humor-skills-and-don’t-give-a-shit-what-you think-doctors” at Facebook (and Twitter) and they have a large like-minded medical audience: the “medical registrar page alone has 19,000 (!) “fans”.

Sadly there is a total lack of reflection and reason in many of the comments. What to think of:

“wow, really. The quasi-academic language and touchy-feely social social science bullshit aside, this woman makes very few points, valid or otherwise. Much like these pages, if you’re offended, fuck off and don’t follow them on Twitter, and cabbage patch to refer to ITU is probably one of the kinder phrases I’ve heard…”

and

“Oh my god. Didnt realise there were so many easily offended, left winging, fun sponging, life sucking, anti- fun, humourless people out there. Get a grip people. Are you telling me you never laughed at the revue’s at your medical schools?”

and

“It may be my view and my view alone but the people who complain about such exchanges, on the whole, tend to be the most insincere, narcissistic and odious little fuckers around with almost NO genuine empathy for the patient and the sole desire to make themselves look like the good guy rather than to serve anyone else.”

It seems these doctors and their fans don’t seem to possess the communicative and emphatic skills one would hope them to have.

One might object that it is *just* Facebook or that “#twitter is supposed to be fun, people!” (dr Fiona)

I wouldn’t agree for 3 reasons:

Doctors are not teenagers anymore and need to act as grown-ups (or better: as professionals)

There is no reason to believe that people who make it their habit to offend others online behave very differently IRL

Seeing Twitter as “just for fun” is an underestimation of the real power of Twitter

12 responses

Thanks for linking back to my post, Laika.
I agree with you, there is no place for comments like these in public fora. I hope that as Anne-Marie has brought this subject to light so eloquently there will be an opportunity for clinicians to reflect a little on the language they use in public, and the effects of their words on the people they aspire to care for.
Thanks again.

It is incredibly narcissistic to claim that if a person is hurt by your crude or careless remark, that person is the one at fault. The offended person must be “overly sensitive” or “humorless”, etc. It is discouraging to think that presumably mature professionals are incapable of the self-reflection and empathy needed to recognize that using social media to amplify their primitive coping style is potentially insulting AND reflects badly on themselves.

Really appreciate your perspective on this topic. As Sarah Stewart said, it is always interesting to read what other people think. Anne-Marie Cunningham’s post was very respectful and considered; an excellent example of reflection. The response to that post has been enlightening. I’ve been thinking about the way that rude, offensive and disparaging terms aimed at the sick and vulnerable are positioned as ‘humour’ and a ‘safety valve’ by the various pundits who seek to validate or excuse such language. There are two aspects of that validation that are worth more consideration. First, that disparaging humour betrays a superiority based ego. Disparaging ‘humour’ is very different to ‘gallow’s’ humour – and just because a female coined the term ‘labia ward’ doesn’t mean the term or intent isn’t misogynist – women can hate women (consciously or unconsciously) as easily as men can – the word is not gender specific in that way.

The other aspect is the most concerning. What I’ve taken from the heart felt efforts to explain why doctors have to engage in rude, disparaging attempts at humour is to do with the inability to properly process the savagery of what they have to deal with day in and day out. There does not appear to be any culture of reflection, clinical supervision and counselling support in the medical profession (apart from perhaps, psychiatry) that would enable doctors to engage in self awareness exercises and develop their social and emotional intelligence/competence. This omission is a grave mistake. The medical profession is obviously suffering. The behaviour we have observed in response to a reasoned, reflective blogpost on a twitter interaction involves some of the greatest examples of defence mechanisms on the planet.

This whole episode flags a real problem within medicine and one that medical educators like Anne-Marie Cunningham are looking at closely. Teaching medical students reflective processes and encouraging a culture of self care will help doctors cope better with the arduousness of their professional practice without them having to resort to unseemly slinging off and disparaging attempts at humour. They need better skills at self management than what they are demonstrating in this situation and it is up to the profession to make sure it is taking care of its members. Every human being deserves that; it is unkind and ultimately dangerous to expect doctors to cope with horrible circumstances without the emotional skills to do so.

I’ve been thinking about how the terms rude, offensive and derogatory directed to the sick and vulnerable are positioned as ‘humor’ and a ‘safety valve’ by experts from several people trying to validate or excuse such language. There Two aspects of this validation, worth further consideration.
Regards,

A very disturbing post. Perhaps the medical profession as a whole should take up regular training in grief education. A colleague of mine regularly goes to Japan to teach grief ed to medical/health professionals. This deals with coping with your own grief and that of others. Another point to remember is that your online activity remain traceable for a very long time. I bet these people don’t want prospective employers to find out this sort of thing …

Whilst I do understand that there is a problem here, I really do, one thing you need to take into account is that doctors deal with deaths and grim situations daily. We can either laugh about it or cry about it. Occasionally we use our own slang. The thing, however, is that the patient or their health is not the butt of the joke, the danger of death is. The term “cabbage patch” is far better than “lots of unconscious people with hardly any hope of ever being the same again”, isn’t it? We use this “slang” to communicate to eachother the needs of patients without freaking them out too much – and yes, we even joke about it because what else can you do? What we do – it’s not easy. In fact, it should go more recognised, the fact that we have to put on a brave face after watching the death of an infant and smile for the next patient. Should we not be allowed some sort of release? As medical professionals, we know the dangers of keeping things locked up inside. And we let it out to the only people who will ever truly understand – each other.

Now, I can understand why it upsets you to see doctors behaving this way in public, but the thing is, doctors are humans too 🙂 Those Twitter accounts… They didn’t specifically say, “Twitter page of Dr. Whatever” not did they broadcast being a doctor, yes? They didn’t go about handing out their Twitter usernames to patients and asking them to follow. Maybe they go home to a wife and kids and at night the chat with their co workers online. I don’t see how this is a problem – if it were a landscaper or a chef or a baker you would expect to see the same. Is it because doctors are put on pedestals? We didn’t ask for that. I don’t want to be held in such high regards that I cannot have a personality outside of the hospital. I’ve posted ridiculous photos from parties in uni, I’ve sent snippy messages to ex boyfriends, I’ve posted a picture of my cat – highly unprofessional, don’t you think? But see, I’m not trying to be professional on Twitter. I’m trying to be me, the me that my old friends got to know in uni, not an all-business doctor. What’s the fun in that? 🙂